02 Jul MEDICAL CONDITIONS AND PLAN LIMITATIONS, PART 1—Pre-Existing Conditions and Mental Health Limitations

MEDICAL CONDITIONS AND PLAN LIMITATIONS, PART 1—Pre-Existing Conditions and Mental Health Limitations

Most long term disability plans contain limitations concerning the type of illness or injury that you have which could affect your claim. This article will discuss two of those limitations: “pre-existing” conditions  and mental health conditions.

1. Pre-Existing Conditions

Pre-Existing condition limitations essentially exclude you from receiving long-term disability benefits for an illness or injury that was diagnosed and/or treated within a certain period of time (often 90 or 180 days) before your LTD coverage began. It is not uncommon for insurance companies to review your medical records if you recently became eligible for LTD benefits to try to find a loophole to exclude you from being covered under the disability policy.

Whether or not the pre-existing condition limitation applies to your situation depends on several factors which should be evaluated by an attorney who regularly handles LTD claims. What does the policy language say? Were you actually treated or diagnosed with your disabling condition during the period of time specified in the policy? If your claim for long-term disability benefits has been denied due to the policy’s pre-existing condition limitation provision, you should contact an ERISA LTD attorney to review the denial immediately.

2. Mental Health Conditions

Another common long-term disability policy limitation concerns those who seek LTD benefits for mental health conditions. If you are unable to work due to a mental health condition, you may be limited under the Plan terms to receive benefits for a certain period of time—usually 12 or 24 months—even if you remain unable to work after longer than that.

As with any long-term disability policy exclusion, it is important to understand what the long-term disability policy actually says, how mental health conditions are defined in the policy, and the effect of inpatient treatment. It is not uncommon for insurance companies to misapply the policy exclusions.

Another common tactic insurance companies use to limit a disabled person’s long term disability benefits is to focus exclusively on the individual’s mental health conditions, ignoring the individual’s physical conditions. It is important to have an attorney who understands the difference between the “disabling” condition, and non-disabling conditions which may co-occur. Understandably, many individuals who have worked very hard their entire life and find themselves unable to continue working due to disability suffer from some degree of depression or anxiety. Unfortunately, many insurance companies will seize on a depression or anxiety diagnosis as a basis to limit the individual’s entitlement to long-term disability benefits to 12 or 24 months.

It is critical that you review your long term disability policy with an ERISA attorney in order to determine whether your benefits should be limited under a mental health condition limitation.